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ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN

ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN. Mudit Mathur, M.D. SUNY Downstate Medical Center. LEARNING GOALS. Impact of Critical Illness Importance of Nutrition Goals of nutritional support Nutritional requirements Enteral vs Parenteral

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ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN

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  1. ENTERAL AND PARENTERAL NUTRITION IN CRITICALLY ILL CHILDREN Mudit Mathur, M.D. SUNY Downstate Medical Center

  2. LEARNING GOALS • Impact of Critical Illness • Importance of Nutrition • Goals of nutritional support • Nutritional requirements • Enteral vs Parenteral • When and how to initiate and advance Nutrition • Monitoring

  3. IMPACT OF CRITICAL ILLNESS-1 • Physiologic stress response : Catabolic phase • increased caloric needs, urinary nitrogen losses • inadequate intake wasting of endogenous protein stores, gluconeogenesis • mass reduction of muscle-protein breakdown

  4. IMPACT OF CRITICAL ILLNESS-2 • Increased energy expenditure • Pain • Anxiety • Fever • Muscular effort-WOB, shivering

  5. RESPONSE TO INJURY

  6. WHY IS NUTRITION IMPORTANTCRITICAL ILLNESS + POOR NUTRITION = • Prolonged ventilator dependency • Prolonged ICU stay • Heightened susceptibility to nosocomial infections MSOF • Increased mortality with mild/moderate or severe malnutrition

  7. NUTRITION: OVERALL GOALSACCP Consensus statement, 1997 • Provide nutritional support appropriate for the individual patient’s • Medical condition • Nutritional status • Available routes for administration

  8. NUTRITION: OVERALL GOALS • Prevent/treat macro/micronutrient deficiencies • Dose nutrients compatible with existing metabolism • Avoid complications • Improve patient outcomes

  9. ENTERAL OR PARENTERAL

  10. IMPACT OF STARVATION-1 • Negative nitrogen balance, further wt loss • Morphological changes in the gut • Mucosal thickness • Cell proliferation • Villus height • Functional changes • Increased permeability • Decreased absorption of amino acids

  11. IMPACT OF STARVATION-2 • Enzymatic/Hormonal changes • Decreased sucrase and lactase • Impact on immunity • Cellular: Decreased T cells, atrophied germinal centers, mitogenic proliferation, differentiation, Th cell function, altered homing • Humoral: Complement, opsonins, Ig, secretory IgA • (70-80% of all Ig produced is secretory IgA) • Increased bacterial translocation

  12. ENTERAL or PARENTERAL? • Enteral Nutrition: Superior to Parenteral • Trophic effects on intestinal villus • Reduces bacterial translocation • Supports Gut-associated Lymphoid Tissue • Promotes secretory IgA secretion and function • Lower cost • Parenteral Nutrition • IV access • Infectious risk

  13. ENTERAL WITH PARENTERALIS THE COMBINATION BETTER • 120 adult patients, (medical and surgical) • Combination vs enteral feeds alone • Prospective, randomized, double blind, controlled • RBP, pre albumin increased significantly D 0-7 • No reduction in ICU morbidity • No reduction in ICU LOS/ vent, MSOF, dialysis • Reduced hospital stay (by 2 days) • Mortality at 90 days and 2 years was identical Bauer et al, Intensive care med. 2000: 26, 893-900

  14. A PRACTICAL APPROACH-1 • Nutritional assessment • History-preexisting malnutrition, underlying disease, recent wt loss (> 5% in 3 wks or >10% in 3 months) • Physical-anthropometrics, BMI, evidence of wasting • Labs-albumin (t ½ 18-21 d), transferrin (t ½ 8 d), prealbumin (t ½ 2 d), RBP (t ½ 0.5 d)

  15. A PRACTICAL APPROACH-2 Assessment of the present illness • Hypermetabolism-burns, sepsis, MSOF, trauma • GI surgical procedures-prolonged NPO • End-organ failure (Hepatic/renal etc) Metabolic Cart-facilitates assessment of energy expenditure, Respiratory Quotient

  16. WHEN TO INITIATE ENTERAL NUTRITION: • ASAP-usually within 24 hours in severe trauma, burns and catabolic states • Contraindications to enteral nutrition: • Nonfunctional gut, anatomic disruption, gut ischemia • Severe peritonitis • Severe shock states

  17. ROUTE OF FEEDING • Nasogastric • Requires gastric motility/emptying • Transpyloric • Effective in gastric atony/ colonic ileus • Silicone/polyurethane tubing • Positioning, Prokinetic agents/ fluoroscopic/ pH/ endoscopic guidance • Percutaneous/surgical placement • PEG if > 4 weeks nutritional support anticipated • Jejunostomy if GE reflux, gastroparesis, pancreatitis

  18. POTENTIAL DRAWBACKS OF ENTERAL FEEDS • Gastric emptying impairments • Aspiration of gastric contents • Diarrhea • Sinusitis • Esophagitis /erosions • Displacement of feeding tube

  19. NUTRITIONAL REQUIREMENTS • 25-30 non protein Kcal/kg/d adult males • 20-25 non protein Kcal/kg/d adult females • Children: BMR 37-55 Kcal/kg/d (50% of EE) + Activity + growth • Factors increasing EE • Fever 12% • Burns upto 100% • Sepsis 40-50 % • Major surgery 20-30%

  20. Resting Energy Expenditure

  21. Factors adding to REE

  22. NUTRITIONAL REQUIREMENTS • Initial protein intake 1.2-1.5 gram/kg/d • Micronutrients-added if feeds are small in volume or patient has excessive losses • Tailor individually, 24-30 cal/oz formula • Usually continuous feeds are tolerated better • Add for catch up growth upon recovery • Adequate calories = adequate growth

  23. FORMULA COMPOSITION • Carbohydrates: 60-70% of non protein calories • Polysaccharides/disaccharides/monosaccharides • Glucose polymers better absorbed • Lipids: 30-40% of non protein calories • Source of EFA • Concentrated calories-but poorer absorption • MCT direct portal absorption-better

  24. FORMULA COMPOSITION • Proteins • -polymeric (pancreatic enzymes required) or peptides • Small peptides from whey protein hydrolysis absorbed better than free AA • Fibers • Insoluble-reduce diarrhea, slower transit-better glycemic control • Degraded to SCFA-trophic to colon

  25. COMPOSITION-SPECIAL FORMULAS • Pulmonary: High fat( 50%), Low CHO • Hepatic: High BCAA, low aromatic AA, <0.5 gm/kg/d protein in encephalopathy • Renal: Low protein, calorically dense, low PO4 , K, Mg GFR >25: 0.6-0.7 g/kg/d GFR <25: 0.3 g/kg/d • Immune-enhancing

  26. IMMUNE MODULATION • Glutamine • Arginine • Fatty acids (w-3) • Nucleotides • Vitamins and minerals Pediatric burn patients: Arginine & w-3 fatty acid supplements reduce infections, LOS ( Gottslisch: J Parenter. Ent. Nutr. 14: 225, 1990)

  27. IMMUNE MODULATION • Glutamine+arginine+Branched chain AA (Immunaid) • Arginine+omega-3 Fatty acids+RNA (Impact) • EN started within 36 hrs • Mortality, bacteremic episodes reduced • More pronounced effect in APACHE II 10-15 Galban et al, CCM, 2000; 28: 3, (643-48)

  28. IMMUNE MODULATIONMECHANISMS ARE UNCLEAR • Reduction of duration and magnitude of inflammatory response • Will this disrupt the balance between pro and anti-inflammatory processes?? • Of the multiple ingredients in these special formulas: which is “the” one • Beneficial effects seen in patients achieving early EN

  29. IMMUNE MODULATION Conclusive studies, clear indications & Cost-benefit analysis are still needed

  30. ENTERAL NUTRITION IN CRITICAL ILLNESS: • Maintains nutritional status • Prevents catabolism • Provides resistance to infection • Potential effect on immune modulation

  31. PARENTERAL NUTRITION (PN) The PN formulation is based on: • Fluid Requirements • Energy Requirements • Vitamins • Trace elements • Other additives-Heparin, H2 blocker etc

  32. Fluid Requirements Fluid requirements = maintenance + repair of dehydration + replacement of ongoing losses. • Maintenance Fluid Requirements 1 - 10 kg = 100 ml/kg/day 10 - 20kg = 1000 ml + 50 ml for each kg > 10 kg 20 kg = 1500 ml + 20ml for each kg > 20 kg • PN generally should be used for the maintenance needs. • Deficit and replacement of losses should be provided separately. • Remember to consider medications, flushes, drips, pressures lines and other IV fluids in your calculations.

  33. Energy Requirements Total Daily Energy Requirements (kcal/day) = Resting Energy Expenditure (REE) + REE  (Total Factors) Factors = Maintenance + Activity + Fever + Simple Trauma + Multiple Injuries + Burns + Growth

  34. PN-suggested guidelines for Initiation and Maintenance

  35. Resting Energy Expenditure

  36. Factors adding to REE

  37. Suggested monitoring Protocol

  38. Calculations Dextrose • ____g/100ml Dextrose  ____ml/day = ____grams/day • _____g/day  (weight  1.44) = _____mg/kg/min • _____g/kg/day  3.4 kcal/g = _____ kcal/kg/day

  39. Calculations Fat • 20 grams/100ml Fat  _____ml/day = _____grams/day • _____g/kg/day  9 kcal/g = _____ kcal/kg/day

  40. Calculations • grams Protein  6.25 = _____ Nitrogen • Non-protein calories  Nitrogen = Calorie:Nitrogen ratio

  41. DANGERS OF OVERFEEDING • Secretory diarrhea (with EN) • Hyperglycemia, glycosuria, dehydration, lipogenesis, fatty liver, liver dysfunction • Electrolyte abnormalities: PO4 , K, Mg • Volume overload, CHF • CO2 production- ventilatory demand • O2 consumption • Increased mortality (in adult studies)

  42. MONITORINGPrevent Overfeeding • Carbohydrate: High RQ indicates CHO excess, stool reducing substances • Protein: Nitrogen balance • Fat: triglyceride • Visceral protein monitoring • Electrolytes, vitamin levels • Caloric requirement assessment by metabolic cart

  43. CONCLUSIONS • Start nutrition early • Enteral route is preferred when available • Set goals for the individual patient • Dose nutrients compatible with existing metabolism • Appropriate monitoring is essential • Avoid overfeeding

  44. QUESTION 1 • When should nutritional support be initiated in critically ill patients? • Only after extubation • After 3 days of NPO status • After 5 days of NPO status • After 7 days of NPO status • ASAP, preferrably within 24 hours of admission

  45. QUESTION 2 • What would be the preferred mode for nutritional support in a 10 year old boy with head injury, raised ICP and aspiration pneumonia that developed after he vomited during intubation in the field. • Parenteral nutrition • Enteral nutrition • A combination of enteral and parenteral nutrition • IV fluids alone until ICP is better controlled.

  46. QUESTION 3 • What would be the initial TPN composition for a 10 kg 18 month year old child • Glucose 10%, Protein 20 g/day, lipids 5g/d • Glucose 10%, Protein 10 g/day, lipids 15g/d • Glucose 15%, Protein 5 g/day, lipids 20g/d • Glucose 12.5%, Protein 20 g/day, lipids 10g/d • Glucose 10%, Protein 10 g/day, lipids 10g/d

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